---
name: medical-adverse-event-review
description: Use when asked to structure, conduct, or write up an adverse event review — a structured investigation into a serious patient-safety event to identify contributing systemic factors — for general educational and structural guidance only, not medical advice; always follow institutional policy and consult the treating clinician or qualified health care professional for actual patient care decisions.
---

# Adverse Event Review

> ⚠️ **Ask your doctor or health care professional. This information is AI generated for education and NOT medical advice.**

An adverse event review is a structured investigation into a serious
patient-safety event, aimed at identifying the systemic factors that
contributed to it and defining concrete changes to prevent recurrence.
It goes beyond the initial factual capture to ask why the event was
possible in the first place.

## Key components

- **Factual timeline** — a reconstruction of what happened, built from
  medical records, monitoring data, medication records, and firsthand
  accounts from everyone involved, not from a single person's memory of
  the sequence.
- **Contributing systemic factors** — the conditions that made the
  event likely, examined across categories such as staffing levels,
  process design, communication and handoff, equipment, and the
  physical environment, not just the final visible action that
  preceded the event.
- **Concrete corrective actions** — specific changes, each with a named
  owner and a follow-up date, not just a list of findings. "Improve
  communication" is not a corrective action; "add a structured
  read-back step to the verbal order process by [date], owned by
  [name]" is.
- **Follow-up verification** — confirmation, at a defined later date,
  that each corrective action was actually implemented and is having
  the intended effect.

## Why systemic factors matter more than the final visible error

The person who performed the last visible action before harm occurred
is rarely the only, or even the most important, contributing factor.
That person was usually operating inside conditions — short staffing, an
ambiguous protocol, a missed handoff, a poorly designed form, alarm
fatigue — that made the error more likely for *anyone* in that position.
Stopping the review at "who did it" fixes nothing: the same conditions
remain in place and will produce the same outcome again with a
different person at the point of contact. Reviewing the systemic
conditions is what actually changes the odds of recurrence.

## How it relates to the incident report and the M&M conference

- **vs. [[medical-clinical-incident-report]]** — the incident report is
  the prompt, factual capture of what happened, filed close to the
  event. The adverse event review is the deeper investigation that
  follows, focused on cause and systemic contributing factors.
- **vs. [[medical-morbidity-and-mortality-review]]** — an M&M review is
  typically a recurring peer-review conference format where cases are
  discussed. An adverse event review is the underlying investigation
  process itself, which may or may not later be presented at an M&M
  conference.

## Common pitfalls

- **Review stopping at the individual who made the final visible
  error** — instead of examining the systemic conditions that made that
  error likely, the review ends with a name and a corrective note in a
  personnel file, and nothing about the underlying conditions changes.
- **Findings with no tracked corrective action or follow-up** — a
  review that identifies contributing factors but assigns no owner or
  date produces a document, not a change.
- **Review conducted long after the event** — the longer the delay, the
  more firsthand accounts degrade and the more the timeline depends on
  memory rather than records, weakening the review's conclusions.
- **Treating the review as punitive** — a review perceived as building
  a case against an individual discourages honest, detailed accounts
  from everyone involved, which is exactly what a systemic investigation
  depends on.
- **Corrective actions never re-verified** — assuming a recommended
  change was implemented, without checking, leaves the systemic gap
  open even after the review is formally closed.

## Learn more

- [[medical-clinical-incident-report]] for the initial factual capture
  that may trigger this deeper review.
- [[medical-morbidity-and-mortality-review]] for the peer-review
  conference format some reviewed cases are presented at.
- [[root-cause-analysis]] for the structured technique behind
  identifying genuine contributing factors rather than the first
  proximate cause.
- [[postmortem]] for the technology-systems analog of this
  investigation process.